Critical Review of

PSMIn Petroleum

IndustryHirak DuttaExecutive DirectorOil Industry Safety Directorate27th Sept, 2013

Agenda

Size of Petroleum Industry in India

Pillars of PSM

Systemic approach in PSM

Ignoring warning signals & its consequences

Key Lessons

OISD’s focus in ‘Process Safety Management’

Cornerstones of PSM

Size of the Petroleum Industry in India

Once a petroleum product deficit country, India today is exporter of petroleum products with earnings to the tune of US $ 60 billion per annum

CAPACITY Current Projected (2016-17)

Total Installed refining capacity

~ 215 MMTPA 310.9 MMTPA

Crude oil production capacity ~ 38 MMTPA 41.1 MMTPA

Gas Production capacity ~ 43 BCMPA 90.1 BCMPA

Volume of POL handling ~ 152 MMTPA 186.2 MMTPA

Petroleum Industry in India

India is the 4th largest consumer (at 569 Million Metric Tonnes of Oil Equivalent) in the year 2011, after China, US & Russia.

Petroleum Industry plays a vital role in providing energy security, and contributes towards the overall growth of the country.

Oil & gas Installations normally operate within high temperature & pressure envelope; handling highly hazardous & inflammable HCs.

Therefore, preservation and safety of these vital National assets are of paramount importance.

Process Safety Management

Pillars of Process Safety

Process Safety

Operational Integrity

Maintenance Integrity

Asset Integrity

Proactive

Reactive

Design Constructio

n

Startup Shut down Emergenc

yHandling

System & Procedure

s Best Practices

Warning Devices Engineere

d Safety Devices

Safety Equipmen

tFire

Fighting Facilities

Prevent Detect , Migrate & Control

Event

Systemic Approach in Process Safety Management

Learn from Near Misses

Mock Drills Task Observation Accident-Incident

Change Mgmt. System

Continuous training & Education

Work Permit Internal Audit

Review of P&ID QRA/HAZOP Inc. best engg.

Practices Safety Instrumentation 3D Model Review

PSV ESD BOP SCSSCV

Hazards

HC Detector Alarms in

Control Room

SOP Simulator Pre-com Check

list Blow down System Equipment Spacing Deluge

Accidents do not happen just

like that…

Prior to any major accident there are always warning signs which, had they been responded to, would have averted the incident.

But they weren’t.They were ignored.

Very often there is a whole culture of denial operating to suppress these warning signals.

Professor Andrew Hopkins

Warning signals Process equipment not functioning as intended. Frequent process excursions outside the safe

operating envelope. Continuing Operation with impaired safeguards. Critical safety systems kept in bypassed mode or not

functioning as intended or not tested. Frequent process upsets. Tolerance to failure to follow company’s systems and

procedures. Failure to learn from near misses or previous

incidents. Minor incidents not being reported. Repeat findings occur in the subsequent audits. Inadequacies in safety management system like

failure to perform hazard analysis, failure to recognize & manage change, inadequate follow up on warning signs/ indicators.

Warning signals

Common response by organization

Ignores signals on the premise that these can be addressed later

(or if the problem escalates).

Illustration on failure to recognize warning signals

Buncefield• Failed to recognize that the level gauges were not working properly/

instrumentation system not working.

Bhopal• The critical safety system was kept bypassed / not working properly

for a long period/ No MOC/ improper maintenance.

Richmond, California• 70 % metal loss in gas oil draw-off line from CDU; under the

insulation corrosion; pointed out by inspection.

MHN• Inclement weather - cyclonic conditions; Dynamic positioner of rescue

vessel perhaps impaired.

Illustrations on failure to recognize warning signals

Pemex, Mexico• Ignored the early signal i.e. drop in the pipeline

pressure noted in the control room due to rupture of the LPG pipeline.

Piper Alpha• Short-cuts in Maintenance activities - PSV of the

condensate pump removed but the end flange blinded loosely - hand tightened; Failure to communicate the same by shift operator to the next shift personnel; continued operation with improper fire fighting facilities.

Jaipur• Instrumentation cable was impaired /equipment not

meeting good engineering practices.

Strategy for response

Recognize a warning sign

Focus resources and efforts on gap

liquidation

Investigate the situation to find

facts

Follow up to ensure the issue

is addressed

ResponseStrategy

Analysis of accidents in

Petroleum Industry

CAUSE Total Incidents

Non adherence to SOP

24

Equipment Failure 11

Non adherence to Work permit system

7

Miscreant activities 8

Lack of Supervision 6

Slip/fall, Negligence 14

Total70

Non ad-her-ence

to SOP34%

Equipment Fail-ure16%

Non adherence to Work permit sys-

tem10%

Mi-cre-ant

activ-ities11%

Lack of

Su-per-vi-

sion9%

Slip/fall, Neg-ligen

ce20%

Major Incidents:2012-13(In plant)

Reasons for accidents

Risks are not identified; even where HAZOP study has been carried out mitigation measures not taken.

Improper focus on Asset Integrity Management; poor reliability.

Disregard to the extant systems & procedures.

Inadequate personnel competency

Violation of standard operating procedure.

Knowledge gap & poor supervision.

Key Lessons: OISDs experience

Holistic approach to HSE and Asset Integrity Management is needed to avert major accidents.

Hazardous industry like ours must ensure that the lessons learnt from the accidents are incorporated into the safety management system.

High concern/focus on achieving throughputs and maximizing GRM negatively impacts safety: Safety should not be subservient to achievement of targets.

Benchmarking the safety performance parameters is needed to achieve improvements in Process Safety Management.

Key Lessons

Key Lessons (contd.)

When near-miss / accidents occur:

Diagnose the systematic failure. Don’t look at only what went wrong but recognize

the hazards & way to control the same.

Objectively carry-out accident-incident analysis:

Not for fault finding purpose To identify root causes To improve the system & avoid recurrence.

Building a safety culture through inspiring leadership at all levels is a must.

Focus should be more on leading rather than lagging indicators.

Always adhere to inherent safety principles.

Safety is 24X7 activity; yesterday’s good safety performance does not guarantee todays safety.

No substitute for high diligence thus employee engagement is foremost.

Key Lessons (contd.)

On the following drivers:

Procedures for operation and maintenance (SOP) Hazard Identification Risk reduction Action Plan Focus on leading indicators Management of change Permit to work Plant integrity Critical controls (bypass policy) Incident investigation Process safety training Emergency preparedness

OISD’s Focus

Cornerstones of Safety

Safety

Cornerstones of Safety

Employee Engagement

Managing Asset Integrity

Risk Assessment & Hazard Study

Adherence to System & Procedures Accident Incident Analysis

Management of Change

Thank you for your patience

Questions?